PP117. Measurement of sFlt-1 and PlGF for prediction of pregnancy associated diseases.

INTRODUCTION: Severe preeclampsia is associated with characteristic changes of sFlt-1 and PlGF levels in the maternal serum. OBJECTIVES: The aim of our study is the determination of the predictive value of sFlt-1 and PlGF for preeclampsia and other pregnancy associated diseases in women with a pathological uterine Doppler measurement during the second trimester of pregnancy. METHODS: An updated analysis of an ongoing prospective trial will be presented. Criterion of inclusion was a bilateral pathological uterine Doppler measurement with an increase of the resistance index (RI) >95th percentile and/or a bilateral postsystolic notch during 19 and 24 weeks. Ratio of sFlt-1 and PlGF was repeatedly measured during pregnancy using a full-automated system (Elecsys®, Roche). RESULTS: Presently, we recruited 36 patients. Full data are available from 17 patients. Out of these in 23.5% (n=4) a delivery before 37 weeks was indicated. 41% of all newborns (7/17) showed a birth weight <5th percentile. 23.5% of all patients developed a hypertensive pregnancy disorder but without fulfilling the criterions of preeclampsia. Only two patients had a sFlt-1/PlGF ratio >95th percentile. In both cases we found severe fetal growth retardation. One of them developed a pregnancy related hypertension based on an antiphospholipid syndrome. CONCLUSION: The additional measurement of the sFlt-1/PlGF ratio in a high risk group of pregnancies may improve the prediction of severe pregnancy related diseases during the second trimester. But keeping the low incidence of severe preeclampsia in mind, the measurements seem to be only usefulness in a high risk population. Although we reported presently only of a small part of our study population the sFlt-1/PlGF ratio did not revealed a good specificity for prediction of preeclampsia. Pathological values were also found in cases with fetal growth retardation without signs of preeclampsia.

Protein A immunoadsorption in a pregnant woman with habitual abortion.

The role of antibodies in the occurrence of recurrent spontaneous miscarriage is well known. However there are many controversial issues in the management of habitual abortion. This paper describes the effect of Protein A immunoadsorption on serum levels of these antibodies and its impact on a case of a successfully treated woman in a outpatient department without need for a central venous catheter. Given the favourable clinical results described in our paper we think it may be relevant for some worse cases in clinical practice and will interest your readers.

Elevation in erythroblast count in maternal blood before the onset of preeclampsia.

OBJECTIVE: We recently showed that both maternal and fetal erythroblast counts are elevated in the peripheral blood of pregnant women with preeclampsia. The purpose of this study was to examine whether this elevation actually occurs before the clinical onset of the disorder. STUDY DESIGN: Erythroblasts were enriched and enumerated in 97 maternal blood samples obtained in the second trimester, and results were subsequently correlated with pregnancy outcomes. RESULTS: Significantly higher quantities of erythroblasts (mean, 6041.7 vs 928.9; P =.008) were detected in blood samples obtained from women who later acquired preeclampsia (n = 15) than in blood samples from the control cohort (n = 72). Intrauterine growth restriction (n = 10) was not accompanied by a similar rise in erythroblast count. CONCLUSION: Because a large proportion of the erythroblasts in maternal blood are fetal, our data suggest that fetal-maternal cell traffic is affected early in pregnancies that are later complicated by preeclampsia but not in those affected only by intrauterine growth restriction.

Ultrasonographic detection of asymptomatic endometrial cancer in postmenopausal patients offers no prognostic advantage over symptomatic disease discovered by uterine bleeding.

The aim of this study was to investigate whether endometrial carcinoma (EC) screening by transvaginal sonography (TVS) has a prognostic advantage over symptomatic EC. In a retrospective study, 190 postmenopausal patients with symptomatic EC and 123 asymptomatic patients with suspicious endometrium detected by TVS were analysed regarding clinical, socio-economic and histopathological findings. Total bleeding time and the International Federation of Gynecology and Obstetrics (FIGO) tumour stage were evaluated with respect to their effect on survival. In 123 asymptomatic patients with suspicious endometrium, 16 (13%) EC, 61 (50%) polyps, 21 (17%) hyperplasias, 23 (19%) atrophias, 1 (0.8%) myoma and 1 (0.8%) metastasis were found. TVS findings in asymptomatic patients resulted in unnecessary operations, which were associated with considerable costs totalling at least 116256. Compared with screened asymptomatic patients, symptomatic patients were significantly (P<0.05) older, more frequently obese, and hypertensive, had a larger proportion of cases living in rural areas and visited their gynaecologists rarely. The bleeding time of symptomatic patients strongly correlated with the tumour stage (P<0.0001). Depending on the bleeding time, the 5-year disease-free survival and overall survival rates were 77% and 86% (no bleeding), 83% and 98% (<8 weeks), 74% and 90% (8-16 weeks), and 62% and 69% (>16 weeks), respectively. The corresponding tumour stage-related data for disease-free and overall survival were 100% (Ia; both rates), 87% and 95% (Ib), 66% and 93% (Ic), 63% and 78% (II) and 36% (III/IV; both rates), respectively. Postmenopausal vaginal bleeding represents an early symptom of EC, but it is not always perceived as problematic by the patients. There is no prognostic advantage for screened compared with symptomatic patients, who had bleeding of shorter than 8 weeks. Moreover, patients who are at a high risk for EC tend to avoid TVS screening. Finally, endometrial screening often results in unnecessary operations, which are associated with increased morbidity and costs.

Effects of adjuvant tamoxifen on the endometrium in postmenopausal women with breast cancer: a prospective long-term study using transvaginal ultrasound.

PURPOSE: To study the value of transvaginal ultrasound (TVS) in endometrial screening of postmenopausal breast cancer patients treated with tamoxifen. PATIENTS AND METHODS: In 247 tamoxifen-treated (20 to 30 mg/d for >/= 2 years) women and 98 controls, the endometrium was prospectively followed-up by means of TVS every 6 months for up to 5 years. Patients with homogeneous endometrium of more than 10-mm thickness were then scanned repeatedly every 3 months. RESULTS: The mean endometrial thickness was 3.5 +/- 1.1 mm before treatment and increased to a maximum of 9. 2 +/- 5.1 mm after 3 years of tamoxifen application (P: <.0001), which was significantly (P: <.0001) thicker compared with controls. Fifty-two asymptomatic patients with thickened or morphologically suspect endometrium underwent hysteroscopy and dilatation and curettage (D&C), resulting in four uterine perforations. Histopathologically, atrophy was found in 38 patients (73.1%), polyps in nine, hyperplasia in four, and endometrial cancer in one case. In 20 screened patients who reported vaginal bleeding, five atrophies (25%), five polyps, four hyperplasias, and two endometrial cancers were found. Before hysteroscopy and D&C were performed, 36 (69.2%) of 52 asymptomatic and four (20%) of 20 symptomatic patients were scanned by repeated TVS over 2 to 30 months. Invasive diagnostic procedures were significantly (P: <.05) more frequent in younger and obese patients. In the controls, one asymptomatic polyp and one symptomatic hyperplasia were found. CONCLUSION: In tamoxifen-treated patients, TVS offered a high false-positive rate, even with a cutoff value of 10 mm for endometrial thickness and repeated TVS scans. Increased iatrogenic morbidity and only one asymptomatic endometrial carcinoma do not warrant endometrial screening by TVS in tamoxifen-treated patients.

Simple ovarian cysts in premenopausal patients.

OBJECTIVE: To compare clinical, ultrasonographical, and cytological findings with the histopathological diagnosis of unilocular, anechoic smooth-walled cystic ovarian tumors ('simple ovarian cysts'). METHOD: In 140 premenopausal women simple ovarian cysts were removed by laparoscopy following ultrasound evaluation. In this retrospective study the histopathological diagnosis was correlated with clinical data, sonographic characteristics, macroscopic impression and with cytological findings. RESULTS: Histopathology revealed 21 (15.0%) functional cysts, 31 (22.1%) retention cysts, 9 (6.4%) endometriomas, 3 (2.1%) cystic teratomas, 12 (8.6%) undifferentiated cysts and 64 (45.7%) cystadenomas. No mentionable differences were correlated with the patient's age or the size of the cyst as determined by ultrasound. Classically, 'chocolate-like' cystic fluid characterizes endometriomas. However, in the present study cysts with different histopathological classifications exhibited similar fluid characteristics. The cytological diagnosis was correct in only 53 (37.9%) of all 140 cases. CONCLUSION: In premenopausal women differential diagnosis of ovarian cysts is not possible by clinical characterization, either by ultrasound or cytological evaluation. Simple ovarian cysts should be observed for at least 8 weeks or 2 menstrual cycles, respectively. If persisting over that period, the ovarian cyst should be removed by laparoscopy, but not by cyst aspiration.

[Histology and cytology of laparoscopically operated "simple ovarian cysts"]. / Histologie und Zytologie laparoskopisch operierter "simpler Ovarialzysten".

In a retrospective study the histopathological findings of 127 laparoscopically operated unilocular anechoic smooth-walled ovarian cysts have been correlated with clinical characteristics (age, duration of observation, complaints, hormonal treatment), size by ultrasound, kind and colour of cysts content as well as cytological findings. The age of patients differed from 16-61 years (mean +/- s: 36 +/- 16). The histopathologic findings yielded 15 (11.8%) functional cysts, 30 (23.6%) persistent corpus luteum cysts, 9 (7.1%) endometriomas, 7 (5.5%) cystic teratomas, 9 (7.1%) undifferenciated cysts and 57 (44.9%) cystadenomas. There were no differences between histopathologic diagnosis groups according to age and cysts size by ultrasound. Functional cysts with complaints (n = 6) may explain that the observation time in 60% of all functional cysts was smaller than 6 weeks, whereas persistent corpus luteum cysts, endometriomas, cystic teratoma and cystadenomas had been observed for longer than 6 weeks in more than two thirds. Intraoperative evaluation of cysts content as "chocolate"-like was suspicious of endometriomas, but was also present in cysts of other histopathological findings. By means of cytology, endometrioma (siderophages) was suspected in 44.4% and a cystadenoma in 42.1% of all histopathologically verified cases. In all, the cytologic findings were useful for correct histopathological diagnosis in only 33.9% of all 127 cases. It is concluded that differential diagnosis of simple ovarian cysts is not possible by clinical characteristics, neither by ultrasound nor by cytological evaluation. Ovarian cysts should be observed for at least two hormonal cycles. A hormonal treatment by combination preparations containing high doses of oestrogen is also recommended. In cases of persisting ovarian cysts laparoscopic removal is necessary.

[Changes in surgical treatment of cystic teratoma--620 cases]. / Der Wandel in der operativen Behandlung zystischer Teratome--620 Fälle.

Among 3492 patients with ovarian tumors subjected to operation between 1/1957 and 3/1994 at the Department of Obstetrics and Gynaecology at the University of Rostock 620 (17.8%) cases of teratomas were found. Histology findings, age, tumor size, bilaterality and malignity of these 620 cases were analyzed. The histologic differentiation yielded 604 (17.3%) mature teratomas (dermoid cysts), 15 monodermale and 1 immature teratoma. Division of total period in the time before and after 1990-since then we have got the possibility of laparoscopic operation-reveals that presumably by increasing use of ultrasound a decrease in mean age at time of diagnosis from 40.2 +/- 20 to 30.7 +/- 12 as well as in tumor size (9 +/- 4 resp. 4 +/- 2 cm) has been achieved. A secondary malignant transformation of epithelial component has been found in 0.5% (3/604) and bilaterality in 11% of the cases. With regard to general rules of laparoscopic operations the intact dermoid cyst enucleation is recommended in premenopausal and extirpation in postmenopausal women. For opening, reduction of volume, and removal of the dermoid cyst from the abdominal cavity, an endo-bag or endo-catch respectively should be used.

[Intrauterine intraperitoneal transfusion controlled by ultrasound. A case report]. / Intrauterine intraperitoneale Transfusion unter Ultraschallkontrolle. Ein Fallbericht.

Two intrauterine transfusions in one fetus have been performed utilizing continuous ultrasound supervision by Sonolayer SSA-90 A in the 31st and 33rd gestational week.

[Perioperative chemoprevention with metronidazole in cesarean section]. / Perioperative Chemoprophylaxe mit Metronidazol beim Kaiserschnitt.

96 caesarean section patients received 2.5 g of metronidazole rectally to prevent infection 6 or more hours after rupture of membranes. The treatment was continued until 30 hours after operation. The febrile morbidity rate was 34.3% in spite of prophylaxis. We conclude that this form of prophylaxis is not appropriate for high-risk caesarean sections.